Percutaneous endoscopic gastrostomy and jejunostomy: endoscopic highlights

Percutaneous endoscopic gastrostomy and jejunostomy: endoscopic highlights

0016-5107/84/3005-0306$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy Spectrum Percutaneou...

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0016-5107/84/3005-0306$02.00 GASTROINTESTINAL ENDOSCOPY Copyright © 1984 by the American Society for Gastrointestinal Endoscopy

Spectrum

Percutaneous endoscopic gastrostomy and jejunostomy: endoscopic highlights Jeffrey L. Ponsky, MD Cleveland, Ohio

Percutaneous endoscopic gastrostomy is a technique which provides for the creation of a gastrostomy without the necessity for laparotomy or general anesthesia. It has been used most effectively in patients requiring long-term enteral alimentation. Such patients have included those with severe neurological impairment, tumors of the oral cavity, and facial trauma. The following photographs demonstrate the important endoscopic features of the procedure. Figure 1. The patient is supine. The stomach is inspected and fully inflated. A site proximal to the angulus on the anterior wall will be chosen for the gastrostomy. Figure 2. After noting the light of the gastroscope to transilluminate the abdominal wall, the assistant applies finger pressure to the selected site in the upper abdomen, just to the left of the midline. The endoscopist must see a definite indentation of the gastric wall at this site as pictured here. This indicates close contact of the gastric and abdominal walls and is the exact site where puncture will occur. Figure 3. As the assistant continues to apply finger pressure to the selected site on the abdominal wall, the endoscopist opens the snare and is ready to surround the needle as it enters the stomach at this point. Figure 4. The needle has punctured the stomach and is surrounded by the snare. The snare is gently tightened around the needle. The metal stylet inside the needle catheter is removed after the snare has been tightened. From the Department of Surgery, Case Western Reserve University School of Medicine, and The Mt. Sinai Medical Center, Cleveland, Ohio. Reprint requests: Dr. Ponsky, The Mt. Sinai Medical Center, University Circle, Cleveland, Ohio 44106.

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Figure 5. The assistant passes a 60-inch #2 silk suture through the catheter into the stomach. The silk can be seen to exit the catheter into the gastric lumen. Figure 6. After several inches of silk have entered the stomach, the snare is opened and allowed to slip from around the catheter and onto the silk suture. Figure 7. The snare is tightened around the silk suture. No attempt is made to pull the snare or suture into the biopsy channel of the gastroscope. The entire scope-snare-silk complex is pulled out of the patient's mouth. The assistant allows the silk suture to run freely at the abdominal end. After the silk has emerged from the patient's mouth, the assistant may remove the catheter from the abdominal wall, leaving the silk in place. Figure 8. The gastrostomy tube is seen being pulled retrograde into the stomach. The gastroscope is reinserted before the tube is fully pulled into position. The endoscopist instructs the assistant to slowly pull the silk until the crossbar behind the mushroom head of the catheter comes into contact with the gastric mucosa. Figure 9. The gastrostomy tube is seen to lie in the correct position. Excessive tension on the catheter is avoided as it will cause necrosis of the interposed tissue. The assistant applies an outer crossbar, and the procedure is complete. Figure 10. This plate demonstrates a catheter modified for percutaneous endoscopic jejunostomy. It is inserted in similar fashion. The mushroom catheter decompresses the stomach, while the long Silastic tube feeds the small intestine more distally. Figure 11. The Silastic feeding tube from the percutaneous endoscopic jejunostomy is deposited into the duodenal bulb using the foreign body forceps.

GASTROINTESTINAL ENDOSCOPY

VOLUME 3D, NO.5, 1984

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